Insulin Smoking

Lifestyle changes should address other risk factors for cardiovascular disease including obesity, physical inactivity, insulin resistance, dyslipidemia, smoking cessation, and others. 

GR is a 68-year-old African-American male who presents to the emergency department with dizziness and loss of speech that began 1 hour ago. His past medical history is significant for hypertension, diabetes mellitus, hypercholesterolemia, and benign prostatic hypertrophy (BPH). Social history is significant for smoking 1 pack per day for the last 38 years. Current medications include metoprolol 50 mg twice daily, insulin NPH 20 units twice daily, and simvastatin 20 mg daily. 

The patient is taking glyburide for non-insulin-dependent diabetes mellitus and has been treated in the past for peptic ulcer disease with ranitidine and omeprazole. He has a history of allergy to various types of pollen but reports no allergies to drugs. He reports moderate consumption of alcohol and smoking 2 packs of cigarettes per day. 

Liu, C., F. Lian, D. E. Smith, R. M. Russell, and X. D. Wang. 2003. Lycopene supplementation inhibits lung squamous metaplasia and induces apoptosis via up-regulating insulin-like growth factor-binding protein 3 in cigarette smoke-exposed ferrets. Cancer Res 63(12) 3138-3144. 

Becker RHA, Sha S, Frick AD, Fountaine RJ (2006) The effect of smoking cessation and subsequent resumption on absorption of inhaled insulin. Diabetes Care 29 277-282. 

Wise S, Chien J, Yeo K, Richardson C (2006) Smoking enhances absorption of insulin but reduces glucodynamic effects in individuals using the Lilly-Dura inhaled insulin system. Diabet Med 23 510-515. 

Smoking cessation, with or without nicotine substitutes, may alter response to concomitant medication in ex-smokers. Smoking may affect alcohol, benzodiazepines, beta-adrenergic blockers, caffeine, clozapine, fluvoxamine, olanzapine, tacrine, theophylline, clorazepate, lidocaine (oral), estradiol, flecanide, imipramine, heparin, insulin, mexiletine, opioids, propranolol, catecholamines, and cortisol. 

Drugs that may require dosage reduction with smoking cessation acetaminophen, caffeine, imipramine, oxazepam, penfazocine, propranolol, fheophylline, insulin, prazocin, labetalol... 

Beta-blockers interact with a large number of other medications. The combination of beta-blockers with calcium antagonists should be avoided, given the risk for hypotension and cardiac arrhythmias. Cimetidine, hydralazine, and alcohol all increase blood levels of beta-blockers, whereas rifampicin decreases their concentrations. Beta-blockers may increase blood levels of phenothiazines and other neuroleptics, clonidine, phen-ytoin, anesthetics, lidocaine, epinephrine, monoamine oxidase inhibitors and other antidepressants, benzodiazepines, and thyroxine. Beta-blockers decrease the effects of insulin and oral hypoglycemic agents. Smoking, oral contraceptives, carbamazepine, and nonsteroidal anti-inflammatory analgesics decrease the effects of beta-blockers (Coffey, 1990). 

The dose of inhaled insulin is about 10 times higher than the subcutaneous dose that produces the same hypoglycemic effect. In an open, randomized, crossover study subcutaneous insulin was compared with a 10 times higher dose of inhaled insulin in 15 non-smoking patients with type 2 diabetes (262). The peak action of inhaled insulin was earlier. Apart from that, the effects were similar. There were no differences in FEVi at baseline or at 4 or 8 hours after treatment. Absorption of inhaled insulin is significantly higher in smokers (263). In non-diabetics, absorption is reduced in asthma (264). Inhaled insulin may increase the titer of insulin antibodies (265). 

Himmelmann A, Jendle J, Mellen A, Petersen AH, Dahl UL, Wollmer P. The impact of smoking on inhaled insulin. Diabetes Care 2003 26(3) 677-82. 

Plaque ruptures in the ACS setting are often involved with a diffuse process, Inflammation is involved in plaque growth and development in addition to complications of plaque rupture. These could be considered the result of injury, Well-known coronary risk factors can provide the impetus for plaque development. Cigarette smoking, hypertension, hyperlipidemia, hyperglycemia, or insulin resistance are noxious stimuli. The stimuli can facilitate monocyte attachment to endothelial cells. Eventually monocytes migrate to the subintimal space and become foam cells to initiate plaque development. 

Lifestyle factors have been associated with ED in both cross-sectional and longitudinal studies. In particular, obesity and sedentary lifestyle are clear-cut risk factors for ED, both in men with comorbid illnesses such as hypertension and diabetes, and especially in men without overt cardiovascular disease (50). Other lifestyle factors, such as smoking and alcohol consumption, have been implicated in some, but not all, studies to date. Intervening on cardiovascular and lifestyle factors may have broader benefits beyond restoration of erectile function. This important concept needs careful consideration, as recent studies have implicated the role of the metabolic syndrome, obesity, insulin resistance, and lack of exercise as independent risk factors for both ED and cardiovascular disease (51,52). 

Mr CD, a 75-year-old man, 1.7 m tall, is admitted to hospital very short of breath. He used to work in the docks as a clerk and has smoked 40 cigarettes daily for 30 years and stopped 2 years ago. His previous medical history includes COPD, recurrent infective exacerbations since 1991, no LTOT type 2 diabetes mellitus on insulin 14 IU b.d. for 20 years, retinopathy ischaemic heart disease - coronary artery bypass graft (twice), hypertension myocardial infarction 1986 atrial fibrillation high cholesterol. 

Amfebutamone has been linked to 41 deaths (17). From the reports of suspected adverse events received by the Netherlands Pharmacovigilance Foundation, it appears that more than half concerned patients at risk of smoking-related diseases. In 15 cases there had been simultaneous use of amfebutamone with another antidepressant (10 patients), theophylline (1 patient), or insulin (4 patients). These combinations may lead to an increase in the risk of seizures. Furthermore, two patients reported having taken antiepileptic drugs, despite the fact that amfebutamone is contraindicated in patients with seizure disorders. These results suggest that the guidelines described in the product information are not being adhered to in some cases. 

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